# Cholelithiasis — GCMD Library living collection

Everything in the library about cholelithiasis — built automatically from dossiers that name it.

Updated: n/a · 7 episodes · 118 cited statements

## Episodes
### Diagnosis & Workup
- [Choledocholithiasis with Drs. David Vitale & Lucas Neff](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884) — podcast · 15:27 · [machine version](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884.md)

### Surgical Management
- [StayCurrent Forums - Laparoscopic Cholecystectomy](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324) — video · 16:04 · [machine version](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324.md)
- [Update Course 2021: THORACOTOMY VS VATS FOR OSTEO METS](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417) — video · [machine version](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417.md)
- [Update Course Rewind: Pediatric Biliary Stones - Surgery First Mindset 2024](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706) — video · 7:31 · [machine version](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706.md)
- [2025 Pediatric Surgery Update Course - Updates in Lap Chole and Cholecystitis Management](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910) — video · 18:17 · [machine version](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910.md)
- [Acute Cholecystitis](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747) — podcast · 32:28 · [machine version](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747.md)

### Case-Based Learning
- [Case-Based Journal Review: Cholelithiasis 2024](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797) — podcast · 18:12 · [machine version](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797.md)

## Chapters
- [0:21](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=21) Introduction and Case Presentation (Ep 1)
- [1:56](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=116) Initial Access and Omental Adhesiolysis (Ep 1)
- [4:29](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=269) Modified Top-Down Dissection and Critical View of Safety (Ep 1)
- [7:21](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=441) Cholangiography Indications and Technique (Ep 1)
- [12:09](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=729) Gallbladder Removal and Hemostasis (Ep 1)
- [14:35](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=875) Postoperative Management and Closing Remarks (Ep 1)
- [0:00](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=0) Introduction and ICG for Cholecystectomy (Ep 2)
- [3:34](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=214) ICG Cholecystectomy Technique and Timing (Ep 2)
- [9:34](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=574) ICG for Partial Nephrectomy and Varicocele Repair (Ep 2)
- [21:24](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1284) Pulmonary Metastasectomy Case Discussion (Ep 2)
- [0:00](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=0) Introduction and case presentation (Ep 3)
- [1:32](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=92) Index admission versus delayed cholecystectomy (Ep 3)
- [4:49](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=289) Predicting common bile duct stones (Ep 3)
- [8:31](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=511) Approach to choledocholithiasis: ERCP versus laparoscopic exploration (Ep 3)
- [13:03](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=783) Indocyanine green fluorescent cholangiography (Ep 3)
- [16:25](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=985) Summary and closing (Ep 3)
- [0:04](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=4) Introduction and Risk Factors for Choledocholithiasis (Ep 4)
- [1:15](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=75) Case Presentation and Risk Stratification (Ep 4)
- [3:34](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=214) Treatment Options: ERCP vs Laparoscopic Exploration (Ep 4)
- [5:07](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=307) Surgery-First Paradigm with Intraoperative Cholangiography (Ep 4)
- [7:41](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=461) Technical Details of Laparoscopic Common Bile Duct Exploration (Ep 4)
- [11:20](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=680) Safety Considerations and Learning Curve (Ep 4)
- [13:48](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=828) Summary and Key Takeaways (Ep 4)
- [0:01](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=1) Introduction and Classification System (Ep 5)
- [1:06](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=66) First Clinical Scenario and Treatment Approaches (Ep 5)
- [2:22](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=142) Surgery-First Evidence and Technique (Ep 5)
- [5:00](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=300) Equipment and Case Selection (Ep 5)
- [5:43](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=343) Second Clinical Scenario: Sickle Cell Patient (Ep 5)
- [6:45](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=405) Summary and Key Takeaways (Ep 5)
- [0:00](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=0) Acute cholecystitis timing controversy and index admission data (Ep 6)
- [4:45](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=285) Reasons for delayed cholecystectomy and gallstone pancreatitis (Ep 6)
- [6:43](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=403) Antibiotic prophylaxis evidence and practice patterns (Ep 6)
- [9:27](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=567) NSQIP compliance and practice changes (Ep 6)
- [10:21](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=621) Enhanced recovery and same-day discharge protocols (Ep 6)
- [13:14](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=794) Surgeon selection and operative volume data (Ep 6)
- [0:00](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=0) Introduction and case presentation (Ep 7)
- [2:30](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=150) Initial management strategy and timing of surgery (Ep 7)
- [5:18](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=318) Management of high-risk patients and percutaneous cholecystostomy (Ep 7)
- [8:00](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=480) Preoperative optimization and cardiac clearance (Ep 7)
- [11:36](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=696) Port placement and initial laparoscopic approach (Ep 7)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- In adult centers, surgeons perform 100 to 300 cholecystectomies per year compared to 10 to 30 per year in pediatric centers — Chiro Esposito (epidemiological) [Ep 2 · 3:34](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=214)
- ICG is a soluble molecule that rapidly binds to albumin and is removed from circulation by the liver into bile juice — Chiro Esposito (clinical) [Ep 2 · 0:23](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=23)
- For cholecystectomy, ICG must be injected 12 to 15 hours preoperatively to allow secretion into bile juice for selective biliary tree visualization — Chiro Esposito (clinical) [Ep 2 · 7:15](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=435)
- If ICG is injected intraoperatively for cholecystectomy, the liver takes up the dye and appears green, making gallbladder identification difficult — Chiro Esposito (clinical) [Ep 2 · 7:51](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=471)
- For all ICG indications except cholecystectomy (kidney, varicocele, lymphoma, tumors), the injection is given intraoperatively — Chiro Esposito (clinical) [Ep 2 · 7:51](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=471)
- ICG vial contains 25 mg in 4 ml, diluted with 10 ml sterile water, with 6 ml injected intravenously for cholecystectomy — Chiro Esposito (clinical) [Ep 2 · 4:40](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=280)
- For partial nephrectomy in duplex kidney, ICG is injected three times: via ureteral catheter to identify normal ureter, intravenously to visualize kidney vasculature, and intravenously again after vessel clipping to show devascularization line — Chiro Esposito (clinical) [Ep 2 · 9:34](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=574)
- In duplex kidney with reflux, the two ureters are attached to each other, making identification of the normal ureter difficult without ICG — Chiro Esposito (clinical) [Ep 2 · 9:34](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=574)
- For varicocele repair, intratesticular injection of 2 ml ICG solution allows intraoperative fluorescence lymphography to identify and spare lymphatic vessels — Chiro Esposito (clinical) [Ep 2 · 17:30](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1050)
- Palomo varicocele repair has success rate of more than 97-98% but ligating lymphatics in the spermatic bundle causes postoperative hydrocele in about 20% of cases — Chiro Esposito (clinical) [Ep 2 · 17:30](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1050)
- In a series of more than 150 varicocele patients using ICG lymphatic sparing technique, there were zero postoperative hydroceles — Chiro Esposito (clinical) [Ep 2 · 19:10](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1150)
- The spermatic bundle contains three to four lymphatic vessels — Chiro Esposito (clinical) [Ep 2 · 17:30](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1050)
- There is no maximum dose limit for ICG based on adult surgery studies — Chiro Esposito (clinical) [Ep 2 · 21:53](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1313)
- ICG vial remains usable for six hours after preparation — Chiro Esposito (clinical) [Ep 2 · 21:24](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1284)
- No adverse effects of ICG were observed in the presenter's experience — Chiro Esposito (clinical) [Ep 2 · 21:24](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=1284)
- ICG technology can be used in both laparoscopy (requiring special camera and optic) and robotic surgery with Da Vinci XI Firefly system — Chiro Esposito (clinical) [Ep 2 · 1:20](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=80)
- The newer Rubin ICG system allows visualization in color with biliary tree appearing green, compared to older systems showing black and white images — Chiro Esposito (clinical) [Ep 2 · 5:40](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=340)
- For elective cholecystectomy cases, patients are hospitalized the day before surgery for ICG injection in the late afternoon if surgery is scheduled early morning — Chiro Esposito (clinical) [Ep 2 · 8:42](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=522)
- ICG technology helps reduce complications in laparoscopic cholecystectomy, particularly beneficial for trainees and in centers with longer learning curves due to lower case volumes — Chiro Esposito (opinion) [Ep 2 · 3:34](https://origin-library.globalcastmd.com/watch/update-course-2021-thoracotomy-vs-vats-for-osteo-mets-5417?t=214)
- Chile has the highest rate of cholelithiasis globally — Jose Campos (epidemiological) [Ep 3 · 1:07](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=67)
- Even in patients with no stones remaining, 2% will get recurrent pancreatitis from the initial insult — Todd Ponsky (clinical) [Ep 3 · 3:44](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=224)
- When patients present with gallstone pancreatitis, most pain and elevated enzymes occur as the stone is passing, and symptoms often resolve overnight as the stone passes — Todd Ponsky (clinical) [Ep 3 · 5:01](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=301)
- If laboratory values normalize after gallstone pancreatitis, ERCP is not indicated, but intraoperative cholangiogram should be performed to check for additional stones — Todd Ponsky (clinical) [Ep 3 · 5:36](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=336)
- For patients with impacted stone, rising lipase, and worsening jaundice, ERCP is preferred because surgeon confidence in retrieving impacted stones intraoperatively is lower — Todd Ponsky (opinion) [Ep 3 · 8:58](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=538)
- The ICG study compared different time periods rather than contemporaneous groups, confounding the comparison with improvements in surgical skill and instruments over time — Jose Campos (opinion) [Ep 3 · 14:25](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=865)
- The ICG study combined all complications without separately reporting common bile duct injuries, and bleeding complications are unlikely attributable to presence or absence of ICG — Jose Campos (opinion) [Ep 3 · 14:43](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=883)
- A complication rate of zero in any surgical series raises methodological concerns — Jose Campos (opinion) [Ep 3 · 14:57](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=897)
- ICG can be administered intravenously, eliminating the need for instrumentation required by traditional intraoperative cholangiogram — Todd Ponsky (clinical) [Ep 3 · 15:21](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=921)
- The ICG study compared ICG to simple visualization without any imaging technique, not to intraoperative cholangiogram, making improved visualization an expected rather than surprising finding — Jose Campos (opinion) [Ep 3 · 15:38](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=938)
- Risk factors for choledocholithiasis include metabolic diseases, hemolysis such as sickle cell, and congenital biliary anomalies like choledochal cysts. — David Vitale (clinical) [Ep 4 · 0:55](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=55)
- Choledocholithiasis is more common in older children, children with higher BMI, and patients of Hispanic ethnicity. — David Vitale (epidemiological) [Ep 4 · 1:03](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=63)
- Retrospective data comparing ERCP versus laparoscopic common bile duct exploration is conflicted and the choice is institution-dependent and provider-dependent based on expertise. — David Vitale (opinion) [Ep 4 · 4:03](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=243)
- Stones above the cystic duct pose a problem because they can float up during attempted laparoscopic removal, making a straightforward procedure much more difficult. — David Vitale (clinical) [Ep 4 · 4:39](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=279)
- Local expertise and availability is the most important factor in the decision tree between ERCP and laparoscopic common bile duct exploration. — David Vitale (opinion) [Ep 4 · 5:00](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=300)
- Dr. Neff uses a 12-gauge angiocath for access, which may be hard to find in pediatric hospitals but can be ordered. — Luke Neff (clinical) [Ep 4 · 9:37](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=577)
- The angle of entry into the cystic ductotomy should be as flat as possible, which is why a new incision is made rather than using existing ports. — Luke Neff (clinical) [Ep 4 · 9:42](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=582)
- Dr. Neff uses a 6 French urethral stent cut down shorter for better flow, with a glide wire inside, using a coaxial technique to navigate the valves of Heister. — Luke Neff (clinical) [Ep 4 · 9:57](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=597)
- Dr. Neff typically uses either a 6 millimeter or 8 millimeter angioplasty balloon, but definitely not more than that. — Luke Neff (clinical) [Ep 4 · 10:37](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=637)
- The balloon dilation technique involves inflating the balloon in the duct, pulling back for tactile feedback to locate the sphincter, partially deflating, straddling the ampulla, then going to full profile under fluoroscopy and holding for about 5 minutes. — Luke Neff (clinical) [Ep 4 · 11:02](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=662)
- Never use a balloon larger than the dilated common bile duct, as adult literature shows higher rates of pancreatitis with ampullary dilation without sphincterotomy. — David Vitale (clinical) [Ep 4 · 11:23](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=683)
- After balloon dilation, Dr. Neff creates a seal on the distal common duct by partially inflating a balloon straddling the cystic duct-common duct junction so that flushing through the guide wire lumen gets pressurized downstream. — Luke Neff (clinical) [Ep 4 · 11:55](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=715)
- If laparoscopic common bile duct exploration is not successful, Dr. Neff places an endoloop on the cystic duct and refers to GI for ERCP. — Luke Neff (clinical) [Ep 4 · 12:16](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=736)
- The prevalence of stone disease is increasing. — Luke Neff (epidemiological) [Ep 4 · 12:34](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=754)
- The learning curve for laparoscopic common bile duct exploration is around 5 to 10 cases, though this is person-specific. — Luke Neff (clinical) [Ep 4 · 13:38](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=818)
- The position of the 12-gauge angiocath is critical, and the ability to manipulate the catheter and wire in the duct depends on the initial setup and how flat the angle of entry is into the cystic duct. — Luke Neff (clinical) [Ep 4 · 13:24](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=804)
- The choice between surgery-first and ERCP-first depends on the setting in which you reside and your own technical capabilities. (opinion) [Ep 5 · 1:50](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=110)
- In patients with BMI under 32-35, Hasson technique is used for initial umbilical port placement — Nathaniel Soper (clinical) [Ep 1 · 2:22](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=142)
- In patients with BMI over 32-35, Veress needle technique is used for initial port placement to avoid large incision required for Hasson — Nathaniel Soper (clinical) [Ep 1 · 2:27](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=147)
- Standard port configuration includes epigastric port (placed last for optimal angle), midclavicular line port, and anterior axillary line port in right upper quadrant — Nathaniel Soper (clinical) [Ep 1 · 3:00](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=180)
- Omental adhesions to chronically inflamed gallbladder can be taken down using low-wattage cautery or harmonic shears at the junction of omentum with underlying tissue — Nathaniel Soper (clinical) [Ep 1 · 3:54](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=234)
- Modified top-down dissection should start approximately one-third of the way up from the infundibulum, not at the fundus — Nathaniel Soper (clinical) [Ep 1 · 5:03](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=303)
- Bilateral dissection technique ("waving the flag") alternating between medial and lateral sides provides better three-dimensional view and more freedom for dissection — Nathaniel Soper (clinical) [Ep 1 · 5:13](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=313)
- Angled laparoscope is superior to 0-degree laparoscope for laparoscopic cholecystectomy — Nathaniel Soper (opinion) [Ep 1 · 5:32](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=332)
- Critical view of safety must be achieved before any irreversible steps such as clipping or cutting structures — Nathaniel Soper (clinical) [Ep 1 · 5:43](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=343)
- Dissecting only on the ventral (left) side of the gallbladder limits freedom of movement and makes dissection more difficult — Nathaniel Soper (clinical) [Ep 1 · 6:11](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=371)
- Intraoperative ultrasound can be performed multiple times during difficult cholecystectomy to identify gallbladder location and bile duct position relative to dissection — Nathaniel Soper (clinical) [Ep 1 · 6:52](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=412)
- Irrigation-suction catheter can be used for blunt (Kittner) dissection in the right hand when there is blood and bile obscuring the field — Nathaniel Soper (clinical) [Ep 1 · 7:33](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=453)
- Indocyanine green (ICG) given too early results in everything appearing bright green, limiting its utility — Nathaniel Soper (clinical) [Ep 1 · 8:12](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=492)
- In cases with significant tissue inflammation, ICG may not adequately visualize ductal structures — Nathaniel Soper (clinical) [Ep 1 · 8:19](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=499)
- Critical view of safety requires complete dissection of fatty material, peritoneal tissue, and scar tissue so the gallbladder infundibulum is separated 1.5 inches from surrounding structures — Nathaniel Soper (clinical) [Ep 1 · 9:14](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=554)
- If critical view of safety cannot be achieved, intraoperative cholangiography is mandatory to clarify ductal anatomy — Nathaniel Soper (clinical) [Ep 1 · 9:59](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=599)
- All residents should learn intraoperative cholangiography technique regardless of selective use in practice — Nathaniel Soper (opinion) [Ep 1 · 10:33](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=633)
- Intraoperative ultrasound should be taught to residents because it allows visualization beyond visible surfaces in the laparoscopic abdomen — Nathaniel Soper (opinion) [Ep 1 · 10:44](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=644)
- Cholangiography adds time and cost, and is not absolutely necessary in the majority of cases — Nathaniel Soper (clinical) [Ep 1 · 10:56](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=656)
- Indications for selective intraoperative cholangiography include uncertain anatomy, cystic duct stones, jaundice, and dilated bile duct on preoperative ultrasound — Nathaniel Soper (clinical) [Ep 1 · 11:11](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=671)
- Before clipping and dividing the cystic duct, place a clip on the gallbladder side, make a small incision, and milk backwards to check for cystic duct stones — Nathaniel Soper (clinical) [Ep 1 · 11:18](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=678)
- Presence of cystic duct stones is a prime indicator that common bile duct stones are also likely present — Nathaniel Soper (clinical) [Ep 1 · 11:35](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=695)
- Chronically inflamed gallbladders are usually intrahepatic with no plane between gallbladder and liver — Nathaniel Soper (clinical) [Ep 1 · 12:25](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=745)
- Controlled avulsion technique for intrahepatic gallbladders involves maximal traction with left hand and minimal contact with low-wattage cautery in right hand at the gallbladder-liver junction — Nathaniel Soper (clinical) [Ep 1 · 12:39](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=759)
- Gallbladder bed hemostasis can be achieved in 99% of cases using cautery with irrigation-suction in left hand and cautery in right hand — Nathaniel Soper (clinical) [Ep 1 · 13:10](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=790)
- For suspected duct of Luschka injury in the gallbladder bed, attempt suture closure but drain placement is usually necessary as sutures are unlikely to hold — Nathaniel Soper (clinical) [Ep 1 · 14:06](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=846)
- Active drain should be placed for deep intrahepatic gallbladder dissection and left in for several hours or overnight to monitor for bile leak — Nathaniel Soper (clinical) [Ep 1 · 14:18](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=858)
- 95% of laparoscopic cholecystectomy patients are discharged home the same day — Nathaniel Soper (clinical) [Ep 1 · 14:40](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=880)
- Postoperative pain management includes intraoperative IV acetaminophen, prescription for only 5 hydrocodone tablets, and recommendation for ibuprofen or acetaminophen for first few days — Nathaniel Soper (clinical) [Ep 1 · 14:52](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=892)
- Pain requiring more than 5 hydrocodone tablets postoperatively suggests a problem and warrants patient contact — Nathaniel Soper (clinical) [Ep 1 · 15:00](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=900)
- Symptoms over a week or 10 days may make cholecystectomy too difficult to operate on during index admission — Jose (opinion) [Ep 6 · 4:55](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=295)
- Practice structure, particularly having an acute care surgery program with rotating coverage, facilitates index admission cholecystectomy — Jose (opinion) [Ep 6 · 5:15](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=315)
- Data supports index operation before discharge even in cases of gallstone pancreatitis to prevent recurrent pancreatitis — Jose (clinical) [Ep 6 · 6:00](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=360)
- NSQIP standardized antibiotic prophylaxis results indicated non-compliance with guidelines when cefazolin was being given, leading to practice change — Jose (clinical) [Ep 6 · 9:35](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=575)
- Index admission cholecystectomy should be the standard for acute cholecystitis after 2025 — Rodrigo Casaz (guideline) [Ep 6 · 17:10](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=1030)
- Antibiotic prophylaxis reduces surgical site infection risk while keeping narrow spectrum treatment as the best choice — Rodrigo Casaz (guideline) [Ep 6 · 17:20](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=1040)
- ERAS principles apply for pediatric laparoscopic cholecystectomy in uncomplicated cases — Rodrigo Casaz (guideline) [Ep 6 · 17:30](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=1050)
- Early discharge after pediatric cholecystectomy is safe and feasible — Rodrigo Casaz (clinical) [Ep 6 · 17:38](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=1058)
- Acute cholecystitis is an obstructive diverticulopathy where the cystic duct becomes obstructed (usually by a stone), causing backup of pressure in the gallbladder with decreased blood flow in the wall, and the wall can eventually rupture. — Jeffrey Ponsky (clinical) [Ep 7 · 4:21](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=261)
- In straightforward acute cholecystitis with symptoms less than two days in a reasonable surgical candidate, early laparoscopic cholecystectomy during the same admission is favored because attempts to cool down have high recurrence rates and patients often return on weekends making management more difficult. — John Rodriguez (opinion) [Ep 7 · 2:46](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=166)
- Preoperative preparation for acute cholecystitis includes admission, antibiotics, NPO status, routine labs, coagulation studies, type and screen, and pregnancy test to avoid delays in operative intervention. — John Rodriguez (clinical) [Ep 7 · 3:58](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=238)
- For patients with significant cardiac history, the last thing you want is to take them to the operating room and cause an acute cardiac event, so cardiology consultation and realistic risk assessment are essential. — John Rodriguez (clinical) [Ep 7 · 5:30](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=330)
- In high-risk patients, antibiotics alone often cool down acute cholecystitis without additional intervention, but percutaneous cholecystostomy tubes can be very helpful for sicker patients who are not good operative candidates. — John Rodriguez (clinical) [Ep 7 · 5:59](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=359)
- For patients who are poor operative candidates, admit to hospital, start broad spectrum antibiotics, and if no improvement after one to two days, recommend percutaneous cholecystostomy. — John Rodriguez (clinical) [Ep 7 · 6:37](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=397)
- Percutaneous cholecystostomy tubes combined with antibiotics are very effective in managing acute cholecystitis in sicker patients, with most having uneventful recovery and hospital discharge. — John Rodriguez (clinical) [Ep 7 · 6:58](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=418)
- Before removing a cholecystostomy tube, wait 4-6 weeks and perform cholangiogram through the tube to ensure the cystic duct is patent; if the duct is not patent, removing the tube will cause recurrent episode. — John Rodriguez (clinical) [Ep 7 · 7:30](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=450)
- Cholecystostomy tubes are useful for timing intervention in patients on antiplatelet therapy for stents who need to wait (e.g., one year) before they can safely come off Plavix or aspirin for definitive surgery. — John Rodriguez (clinical) [Ep 7 · 8:18](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=498)
- Cholecystectomy in patients with prior cholecystostomy tubes are more challenging cases that need to be planned well and should not be added on at the end of a long surgical day when the surgeon is tired. — John Rodriguez (opinion) [Ep 7 · 9:33](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=573)
- Palmer's point is located two finger breadths below the rib cage on the left side in the midclavicular line and is one of the safest locations for initial trocar entry. — John Rodriguez (clinical) [Ep 7 · 12:17](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=737)
- Placing the most lateral trocar while visualizing the gallbladder allows the assistant to grab and elevate it, providing better location for the left hand port. — John Rodriguez (clinical) [Ep 7 · 13:16](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=796)
- When lysing omental adhesions in acute cholecystitis, use cautery (especially when colon and duodenum are visible) because edematous tissue bleeds easily, and uncontrolled bleeding impedes visualization later in the case. — John Rodriguez (clinical) [Ep 7 · 15:32](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=932)
- There is a very low threshold to decompress tense gallbladders before trying to grab them, using a long reusable needle connected via luer lock to a 60cc syringe, inserted under direct vision into the fundus to aspirate. — John Rodriguez (clinical) [Ep 7 · 16:29](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=989)
- Start dissection high up on the gallbladder where you are certain you are on the gallbladder, then gently and patiently tease tissues down toward the duodenum using hook electrocautery. — John Rodriguez (clinical) [Ep 7 · 17:27](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1047)
- As Calot's node is taken down, the cystic artery becomes visible; dissect it up toward the body of the gallbladder to get length, because as long as you are on the gallbladder you are safe. — John Rodriguez (clinical) [Ep 7 · 18:35](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1115)
- The critical view of safety requires visualization of the cystic duct-gallbladder junction, the cystic artery within Calot's triangle, and liver in the dissection window. — John Rodriguez (clinical) [Ep 7 · 19:17](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1157)
- Taking some of the gallbladder just superior to the cystic duct junction and removing the back wall off the liver bed gives increased length for dissection. — Jeffrey Ponsky (clinical) [Ep 7 · 20:18](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1218)
- Dr. Rodriguez uses routine cholangiography in almost all cases. — John Rodriguez (clinical) [Ep 7 · 20:39](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1239)
- For cholangiography, place a clip very close to the gallbladder, make a dicotomy, then milk the cystic duct proximally with scissors or Maryland to express any stones before cannulation. — John Rodriguez (clinical) [Ep 7 · 21:08](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1268)
- The Olsen clamp has a layout where the tip comes together but the middle does not, providing just enough occlusion of the cystic duct around the catheter without occluding the catheter itself. — John Rodriguez (clinical) [Ep 7 · 21:57](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1317)
- Flush the cystic duct with 20cc of saline before cholangiography because when there is sludge and stones, clearing that beforehand is very helpful and also removes air bubbles from the system. — John Rodriguez (clinical) [Ep 7 · 22:18](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1338)
- To get contrast to flow into the intrahepatic ducts when it only goes down initially, place the patient in Trendelenburg position or use the camera to put pressure on the distal common bile duct. — John Rodriguez (clinical) [Ep 7 · 22:56](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1376)
- For a small stone in the distal duct, first try flushing again with good pressure, give glucagon to relax the ampulla, and repeat cholangiogram; if that does not work, use a commercial transcystic common bile duct exploration kit. — John Rodriguez (clinical) [Ep 7 · 23:41](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1421)
- The transcystic CBD exploration kit includes a percutaneous introduction catheter with step dilator; introduce it through a separate stab incision (not through existing trocar) from the right side at a parallel angle to the cystic duct to avoid trauma and backwalling the duct. — John Rodriguez (clinical) [Ep 7 · 24:07](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1447)
- The key for transcystic CBD exploration is to place a wire under fluoroscopic guidance distally into the duodenum; once the wire is down, the kit's basket (Dormia-type) can crush and retrieve stones, or the balloon dilator can push small stones through via antegrade sphincteroplasty. — John Rodriguez (clinical) [Ep 7 · 24:52](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1492)
- When the infundibulum, cystic duct, Calot's triangle and node cannot be defined and dissection is very difficult, be aggressive about going top-down (fundus-down) fashion laparoscopically. — John Rodriguez (clinical) [Ep 7 · 26:14](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1574)
- There is no fear of adding another trocar—they are free and there is nothing magical about one number or another; just put them where you need them. — Jeffrey Ponsky (opinion) [Ep 7 · 27:07](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1627)
- In severe cases, the decision is between doing a partial cholecystectomy or leaving part of the back wall on the liver; sometimes opening the gallbladder, removing all stones, and placing a large cholecystostomy tube can bail you out. — John Rodriguez (clinical) [Ep 7 · 27:52](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1672)
- When going open for a difficult case, top-down (dome-down) dissection is still the preferred approach. — John Rodriguez (clinical) [Ep 7 · 28:21](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1701)
- Some patients have a very superficial right ductal system, and digging too deep into the liver during gallbladder dissection can injure it; many bile leaks labeled as duct of Luschka leaks are actually from the surgeon getting too deep into the liver and injuring the ductal system. — John Rodriguez (clinical) [Ep 7 · 28:47](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1727)
- In subtotal cholecystectomy, open the gallbladder, remove stones, get down to a safe point, close it up (the cystic duct can eventually open again), and leave a drain to control bile leak if it occurs. — John Rodriguez (clinical) [Ep 7 · 29:31](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1771)
- Back-wall preservation is indicated in horrible cases where the gallbladder is necrotic and falling apart and the cystic duct area looks equally bad; it is the safest approach to avoid major bile duct injury. — John Rodriguez (clinical) [Ep 7 · 30:06](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1806)
- When leaving the back wall, cauterize the mucosa with coagulation on a high setting and leave a drain. — John Rodriguez (clinical) [Ep 7 · 30:36](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1836)
- The big goal in difficult cholecystectomy cases is avoiding a major bile duct injury that will end up being a disaster. — John Rodriguez (opinion) [Ep 7 · 30:21](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1821)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- In a multi-center study of 167 early cholecystectomy patients versus 79 delayed, early cholecystectomy had 2% recurrence of pancreatitis compared to 22% in delayed surgery — Cecilia Gigena summarizes what Dr. Jose Campos said [Ep 3 · 3:11](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=191)
- When cholecystectomy was delayed more than 6 weeks after gallstone pancreatitis, recurrence rate increased to 60% — Cecilia Gigena summarizes what Dr. Jose Campos said [Ep 3 · 3:36](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=216)
- Patients who underwent early cholecystectomy did not have more biliary complications than delayed surgery patients — Cecilia Gigena summarizes what Dr. Jose Campos said [Ep 3 · 4:27](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=267)
- A Western Pediatric Surgery Research Consortium machine learning algorithm based on 1600 patients from 10 centers (2016-2019) can predict common bile duct stones using nine clinical factors, with 20% of patients having CBD stones — Em Gootee summarizes what Dr. Jose Campos said [Ep 3 · 6:26](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=386)
- The machine learning algorithm for predicting CBD stones has a negative predictive value of 98%, meaning only 2% chance of missing stones when algorithm predicts low risk — Jose Campos summarizing a resource [Ep 3 · 7:11](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=431)
- The previous algorithm for predicting CBD stones was based on 300-400 patients, compared to 1600 in the new algorithm — Em Gootee summarizes what Dr. Jose Campos said [Ep 3 · 7:33](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=453)
- In a multi-center study of 252 patients with choledocholithiasis, 156 underwent OR-first approach (laparoscopic cholecystectomy with intraoperative cholangiogram) and 96 underwent ERCP-first approach — Cecilia Gigena summarizes what Dr. Jose Campos said [Ep 3 · 11:27](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=687)
- Patients who underwent intraoperative cholangiogram first had fewer complications and shorter length of stay than ERCP-first patients, and 86% needed only the surgery without subsequent ERCP — Cecilia Gigena summarizes what Dr. Jose Campos said [Ep 3 · 11:41](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=701)
- The laparoscopic common bile duct exploration study included 4 centers with a broad range of surgeons, demonstrating feasibility beyond single expert centers — Jose Campos summarizing a resource [Ep 3 · 11:56](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=716)
- Of patients who had ERCP after failed laparoscopic CBD exploration (14% of OR-first group), outcomes were good without increased bile duct leak or complications — Jose Campos summarizing a resource [Ep 3 · 12:15](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=735)
- In the stepwise laparoscopic CBD exploration approach, 84% of patients had stones cleared with saline flush through a ureteral catheter alone — Jose Campos summarizing a resource [Ep 3 · 12:30](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=750)
- In a study of 173 laparoscopic cholecystectomies over 10 years (2013-2023), 83 used standard technique and 90 used ICG fluorescence — Em Gootee summarizes what Dr. Jose Campos said [Ep 3 · 13:34](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=814)
- The ICG study showed perioperative complication rate of 12% in standard technique versus 0% with ICG, with significantly shorter operative times and better biliary visualization in the ICG group — Em Gootee summarizes what Dr. Jose Campos said [Ep 3 · 13:54](https://origin-library.globalcastmd.com/watch/case-based-journal-review-cholelithiasis-2024-8797?t=834)
- Choledocholithiasis stones may be made up of bile pigments or calcium and cholesterol salts. — Cecilia Gigena summarizing the discussion [Ep 4 · 0:43](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=43)
- According to ASGE guidelines, patients with high probability of common bile duct stones (common bile duct stones seen on ultrasound, ascending cholangitis, or quite high bilirubin) should go straight to ERCP. — David Vitale summarizes what Dr. Luke Neff said [Ep 4 · 1:52](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=112)
- Patients with intermediate risk (abnormal liver biochemical tests or dilated common bile ducts) can undergo endoscopic ultrasound, MRCP, laparoscopic cholangiogram, or intraoperative ultrasound. — Cecilia Gigena summarizing the discussion [Ep 4 · 2:11](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=131)
- In pediatric literature, direct (conjugated) bilirubin more than 2 mg/dL was the most predictive factor for common bile duct stones. — David Vitale summarizes what Dr. Luke Neff said [Ep 4 · 2:40](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=160)
- Common bile duct diameter greater than 6 millimeters was most sensitive for predicting common bile duct stones in children, although without statistical significance. — Cecilia Gigena summarizing the discussion [Ep 4 · 2:50](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=170)
- The pediatric duct score (published in Journal of American College of Surgeons with 10 centers) identified three most predictive risk factors: ducts greater than 6 mm, common bile duct stones on ultrasound, or total bilirubin greater than 1.8 mg/dL. — David Vitale summarizes what Dr. Luke Neff said [Ep 4 · 3:03](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=183)
- Pediatric literature with small sample size shows that same-anesthesia laparoscopic cholecystectomy with ERCP in stone disease led to less anesthesia time and lower length of stay. — David Vitale summarizes what Dr. Luke Neff said [Ep 4 · 3:41](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=221)
- Randomized trials from 2013 show no significant difference in morbidity, mortality, retained stones, or failure rates between ERCP and laparoscopic common bile duct exploration. — Cecilia Gigena summarizing the discussion [Ep 4 · 4:18](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=258)
- Most free-standing children's hospitals do not have ERCP capabilities. — Cecilia Gigena summarizing the discussion [Ep 4 · 8:59](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=539)
- If the pancreatic duct is visualized during fluoroscopy, the procedure should be stopped due to higher risk for pancreatitis. — Cecilia Gigena summarizing the discussion [Ep 4 · 12:24](https://origin-library.globalcastmd.com/watch/choledocholithiasis-with-drs-david-vitale-lucas-neff-8884?t=744)
- Stone disease is increasing along with obesity in pediatric patients around the world, not just in the United States. — Em Gootee summarizing the discussion [Ep 5 · 0:52](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=52)
- There are two main approaches for patients with stones in the common bile duct who need gallbladder removal: ERCP first to remove ductal stones followed by laparoscopic cholecystectomy, or laparoscopic cholecystectomy with intraoperative cholangiogram to identify and potentially remove stones during the same surgery. — Em Gootee summarizing the discussion [Ep 5 · 1:25](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=85)
- A surgery-first pathway reduces resource utilization, including MRCP, according to recently published work. — Em Gootee summarizing the discussion [Ep 5 · 2:11](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=131)
- A paper from the Journal of American College of Surgeons defined a very specific and predictive score for cholelithiasis. — Em Gootee summarizing the discussion [Ep 5 · 2:25](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=145)
- ERCP adds potential morbidity to a procedure, and even with good technique, pancreatitis occurs 10% of the time. — Em Gootee summarizing the discussion [Ep 5 · 3:02](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=182)
- If the surgeon cannot do a cholangiogram, then ERCP is needed if someone can do it. — Em Gootee summarizing the discussion [Ep 5 · 3:16](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=196)
- If you know how to put in a central line and understand the principles of Seldinger technique, then you can do intraoperative stone removal. — Em Gootee summarizing the discussion [Ep 5 · 3:44](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=224)
- In a paper published in JPS, stone clearance rate reflected by a negative intraoperative cholangiogram was 86% with a surgery-first mindset. — Em Gootee summarizing the discussion [Ep 5 · 3:50](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=230)
- With minor additional techniques like advancing the catheter into the common bile duct or reaming the sphincter, the success rate was in the 90s. — Em Gootee summarizing the discussion [Ep 5 · 4:01](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=241)
- At Cincinnati Children's, when surgeons cannot clear the duct, they call from the OR and an ERCP can be performed quickly in most cases. — Em Gootee summarizing the discussion [Ep 5 · 4:38](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=278)
- At institutions without access to immediate ERCP, surgeons can place a clip or endo loop, close up, and perform ERCP within the next day or two. — Em Gootee summarizing the discussion [Ep 5 · 4:47](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=287)
- According to Doctor Huntington, the biggest key to success is having all the necessary equipment in one place, because no one in the OR is going to know what to get on the fly. — Em Gootee summarizing the discussion [Ep 5 · 5:15](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=315)
- A common bile duct with 3 or 4 impacted stones is typically not suitable for surgery-first approach. — Em Gootee summarizing the discussion [Ep 5 · 5:26](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=326)
- Doctor Vitale cautions that when flushing, if a stone is impacted, there is a risk of inadvertently injecting contrast into the pancreatic duct, which can increase the risk of pancreatitis. — Em Gootee summarizing the discussion [Ep 5 · 6:03](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=363)
- When the pancreatic duct lights up during flushing, that is a signal to slow down because you can cause pancreatitis by flushing contrast into the pancreatic duct with a stone present. — Em Gootee summarizing the discussion [Ep 5 · 6:15](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=375)
- A study demonstrated an 86% success rate for surgery-first, but the ERCP group had a 10% complication rate, including cholangitis, bleeding, pancreatitis, and hemophilia. — Em Gootee summarizing the discussion [Ep 5 · 6:33](https://origin-library.globalcastmd.com/watch/update-course-rewind-pediatric-biliary-stones-surgery-first-mindset-2024-10706?t=393)
- Dr. Nathaniel Soper is professor and chairman of the Department of Surgery at the University of Arizona College of Medicine at Phoenix — Jeff summarizes what Dr. Nathaniel Soper said [Ep 1 · 0:21](https://origin-library.globalcastmd.com/watch/staycurrent-forums-laparoscopic-cholecystectomy-5324?t=21)
- Index cholecystectomy performed during initial admission reduces readmission rate from 22% to 2-3% according to a 2024 Surgical Endoscopy paper — Rodrigo Casaz summarizing the discussion [Ep 6 · 3:55](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=235)
- Index admission cholecystectomy significantly shortens length of stay from 22 days to 6 days — Rodrigo Casaz summarizing the discussion [Ep 6 · 4:20](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=260)
- Adult Infectious Disease Society guidelines recommend against antibiotic prophylaxis for cholecystectomy citing concerns about antimicrobial resistance, according to a 2025 JAMA article — Rodrigo Casaz summarizing the discussion [Ep 6 · 7:55](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=475)
- A two-center study of over 2000 children found more than 90% received antibiotic prophylaxis for cholecystectomy — Rodrigo Casaz summarizing the discussion [Ep 6 · 8:20](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=500)
- Prophylaxis antibiotics were associated with a 72% reduction in the odds of surgical site infection in pediatric cholecystectomy — Rodrigo Casaz summarizing the discussion [Ep 6 · 8:45](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=525)
- The number needed to treat with prophylaxis to prevent a single surgical site infection was calculated around 35 — Rodrigo Casaz summarizing the discussion [Ep 6 · 9:00](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=540)
- There is no additional benefit from using extended spectrum compared with narrow spectrum antibiotics like cefazolin for cholecystectomy prophylaxis — Rodrigo Casaz summarizing the discussion [Ep 6 · 9:15](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=555)
- A French hospital successfully implemented ERAS protocol for pediatric laparoscopic cholecystectomy in 90% of patients over a five-year period — Rodrigo Casaz summarizing the discussion [Ep 6 · 11:30](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=690)
- There were no postoperative complications or readmissions during 30-day observation in the French ERAS cohort — Rodrigo Casaz summarizing the discussion [Ep 6 · 11:50](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=710)
- At medium-long term follow-up to 55 months, there were no health issues associated with same-day discharge after pediatric cholecystectomy — Rodrigo Casaz summarizing the discussion [Ep 6 · 12:05](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=725)
- A 2024 systematic review from Pediatric Surgery International reviewed over 19,000 pediatric laparoscopic cholecystectomies — Rodrigo Casaz summarizing the discussion [Ep 6 · 15:20](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=920)
- For simple cholecystitis, higher operative volume is the key determinant for favorable outcomes, with high volume more common in adult surgeons — Rodrigo Casaz summarizing the discussion [Ep 6 · 15:40](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=940)
- High volume surgeons showed statistically significant reduction in postoperative complications and 30-day readmission rates — Rodrigo Casaz summarizing the discussion [Ep 6 · 16:05](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=965)
- The systematic review recommends pediatric surgeon participation for more complex children with special needs such as hemolytic disorders — Rodrigo Casaz summarizing the discussion [Ep 6 · 16:30](https://origin-library.globalcastmd.com/watch/2025-pediatric-surgery-update-course-updates-in-lap-chole-and-cholecystitis-mana-10910?t=990)
- Dissection should occur at the junction of the cystic duct and gallbladder, and the cystic artery and gallbladder—not as close to the common duct as possible, which is how you get in trouble. — Jeffrey Ponsky summarizes what Dr. John Rodriguez said [Ep 7 · 18:53](https://origin-library.globalcastmd.com/watch/acute-cholecystitis-13747?t=1133)

## Changelog
- Sep 27: 1 item added automatically
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